Monday, December 12, 2011

A Special Kind of Bedlam

     One of my most vivid recollections from internship was a 36 hour period I spent on my plastic surgery rotation at Grady Medical Center in downtown Atlanta. Unlike the hospital in which I'd rotated as a medical student, this hospital possessed a special kind of bedlam, gyrating wildly within a palpably psychotic parallel universe, the inevitable fallout from servicing such a wide and varied demography. Plastics call was incredibly complex. Aside from covering our own patients, we alternated hand and upper extremity call with orthopaedics every other night. In a similar fashion, we split facial trauma consults with the ENT and oro-maxillofacial services. You didn't have to be a genius to figure out that in a big city with lots of poverty, there was also a lot of crime and fighting, the end result of which was a staggering amount of hand and facial trauma. I spent an inordinate amount of time that month in the emergency room's Red Zone, which was the area devoted to trauma and patients in need of surgery.
     All of us surgery interns had the Red Zone's extension memorized, and when that number showed up on your pager, you experienced an immediate sinking feeling, sort of an internal Mr. Bill "Oh noooooooooo!" On this particular evening, I had already been in the hospital since about 3:30 a.m. The Plastics service was full, and I had spent much of the day, changing dressings, arranging placement for the homeless patients, repairing lacerations and lancing abscesses in urgent care, and dealing with other various and sundry logistical issues. As usual, someone had stolen my frozen dinner from the refrigerator in the 6th floor break room, and I was forced to subsist for the rest of the night on graham crackers and whatever morsels I could find in the anesthesia lounge. I tried lying down in the call room, but my pager sounded around 10 p.m., and quelle surprise, it was the Red Zone.
     The unidentified voice on the other end of the phone was requesting a plastics consult on a patient who had come in with facial injuries after hitting his head on the steering wheel in a motor vehicle accident. His head, neck, spine, chest, and abdomen had been cleared from a trauma standpoint, but his face was in dire need of attention. I think he may have had a little bit of alcohol on board, but he wasn't overtly intoxicated, and was cooperative and quite pleasant. I inspected his injuries, and my first thought was that he really needed to go to the operating room to have his wounds washed out. Starting at his upper lip, he had a through-and-through tear which extended from the vermilion border, traversed the philtrum, and terminated so far back into the confines of his nasal turbinates, I could hardly visualize it with my penlight. These wounds were deep, filled with smutty debris, and there was dried and oozing blood everywhere. I had no idea what on earth to do with him.
     I phoned the plastics fellow on call to appraise him of the situation. Much to my dismay, he proceeded to instruct me that I was to close the patient's lacerations in three different layers using three kinds of sutures, right there in the Red Zone. Using my Palm Pilot, I jotted his instructions down, and proceeded to gather my supplies. In the emergency room, you learned very quickly to be resourceful and self-sufficient because there just weren't any extra nursing staff available to help you. I found warm saline, betadine, a plastic basin, and a giant bulb syringe for irrigating the wounds. I checked out lidocaine with epi and several syringes with 27 gauge needles for injecting local to numb up his skin. I located the three different types of sutures I needed, along with a suture kit, several packs of sterile gloves, and some gauze sponges. Then, i got to work.
     The patient was a young guy in his 20s. I explained to him that I was going to repair his lacerations, and that it was going to take awhile. His nurse brought some morphine to help sedate him and ease the pain, and I was very thankful at that point for whatever alcohol was left in his system. He was surprisingly calm. After thoroughly irrigating his wounds, I began injecting the local anesthetic into his skin and subcutaneous tissue, praying it wouldn't reach a toxic blood level. The plastics fellow had given me a very detailed description of how to line up the edges of the vermilion border and philtrum in order to get a satisfactory closure. It took several attempts, but the final result was impressive. I was on a roll. As I plodded along with my suturing, my pager was furiously beeping, with consults and calls coming through every fifteen minutes or so. Initially, I returned the calls, but each time I answered my pager, I had to get new sterile gloves, which killed more time, so I quickly abandoned that endeavor. The structures in the back of my patient's nose took the longest to close, and when I finally finished, it was already around two in the morning. I was exhausted. Based on the number of times my pager went off, I knew I had a day's worth of consults stacking up. I managed to get a couple hours of sleep, then started pre-rounding on our patients. Once I'd finished rounding with the plastics fellows, I began seeing the consults left over from the night before.
     That day seemed interminable: were it not for those consults, I would have gotten to go home after rounds. Around 8 p.m., I finally saw the last consult, who still happened to be down in the Red Zone, and before going home, I stopped by to see my patient from the night before, the one whose face I'd spent 4 hours sewing. He, and the suturing, looked great, and he actually thanked me. I don't remember driving home that night. Somehow, I ended up at the airport, about 20 miles away, and had to call my husband because I had gotten lost; he stayed on the phone with me the rest of the drive home. Once I got home, I had a quick dinner and collapsed into bed, setting my alarm for 3:30 a.m., when I would awaken and do it all over again.

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